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Clinical policy bulletins
Clinical Policy Bulletins Alphabetical List
Clinical Policy Bulletins
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Pharmacy Policy Bulletins
A
B
C
D
E
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I
J
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R
S
T
U
V
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X
Y
Z
A
Abatacept (Orencia) - CPB 0720
Abdominal Aortic Aneurysm Screening - CPB 0702
Abdominoplasty,Suction Lipectomy, and Ventral Hernia Repair - CPB 0211
Ablation of Hepatic Lesions - CPB 0274
Acoustic Heart Sound Recording and Computer Analysis - CPB 0692
Acoustic Pharyngometers and SNAP™ Testing System - CPB 0336
Actigraphy and Accelerometry - CPB 0710
Actinic Keratoses Treatment - CPB 0567
Acupuncture - CPB 0135
Acute Ischemic Stroke: Treatments - CPB 0789
AcuTect Scintigraphic Imaging for Detection of Lower Limb Deep Vein Thrombosis - CPB 0414
Adalimumab (Humira) - CPB 0655
ADAMTS13 Assay for Thrombotic Thrombocytopenic Purpura (TTP) - CPB 0780
Adoptive Immunotherapy - CPB 0641
Aerosolized or Irrigated Anti-infectives for Sinusitis - CPB 0593
Age-Related Macular Degeneration: Treatments - CPB 0765
Alemtuzumab (Campath) - CPB 0764
Allergy and Hypersensitivity - CPB 0038
Allogeneic Bone Marrow or Peripheral Stem Cell Transplant for Aplastic Anemia and Other Bone Marrow Failure Syndromes - CPB 0627
Allogeneic Bone Marrow or Peripheral Stem Cell Transplant for Thalassemia Major and Sickle Cell Anemia - CPB 0626
Allograft Transplants of the Extremities - CPB 0364
Alopecia Areata - CPB 0423
Alpha 1-Antitrypsin Inhibitor Therapy - CPB 0145
Alzheimer's Disease Diagnosis - CPB 0349
Alzheimer's Disease: Experimental Treatments - CPB 0788
Ambulatory Assist Devices: Walkers, Canes, and Crutches - CPB 0505
Ambulatory Electroencephalography - CPB 0425
Amnioinfusion - CPB 0417
AmniSure ROM (Rupture of Membranes) Test - CPB 0757
Analysis of Volatile Organic Compounds to Detect Bacteriuria - CPB 0717
Androgens and Anabolic Steroids - CPB 0528
Anecortave Acetate (Retaane) - CPB 0706
Anesthetic Infusion Pumps - CPB 0607
AngioJet Rheolytic Thrombectomy System - CPB 0568
Angioplasty and Stenting of Extra-Cranial and Intra-Cranial Arteries - CPB 0276
Ankle Orthoses, Ankle-Foot Orthoses (AFOs), and Knee-Ankle-Foot Orthoses (KAFOs) - CPB 0565
Antepartum Fetal Surveillance - CPB 0088
Anterior Segment Optical Coherence Tomography - CPB 0749
Anthrax Vaccine - CPB 0483
Antibody Tests for Neurologic Diseases - CPB 0340
Antiemetic Injection Therapy - CPB 0724
Antineoplaston Therapy and Sodium Phenylbutyrate - CPB 0240
Antiprothrombin Antibody Testing - CPB 0662
Antroduodenal Manometry - CPB 0616
Apnea Monitors for Infants - CPB 0003
Artificial Retina - CPB 0713
Athletic Pubalgia Surgery - CPB 0750
Attention Deficit/Hyperactivity Disorder - CPB 0426
Auditory Processing Disorder (APD) - CPB 0668
Aural Rehabilitation - CPB 0034
Autologous Chondrocyte Implantation - CPB 0247
Autologous Skeletal Myoblast/Mononuclear Bone Marrow Cell Transplantation for Cardiac Diseases - CPB 0599
Automated Ambulatory Blood Pressure Monitoring - CPB 0025
Autonomic Testing / Sudomotor Tests - CPB 0485
Autotransfusers - CPB 0639
Axial Lumbar Interbody Fusion (AxiaLIF) - CPB 772
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B
Back Pain - Invasive Procedures - CPB 0016
Back Pain – Non Invasive Treatments - CPB 0232
Balloon Dacryocystoplasty / Dacryoplasty for Nasolacrimal Duct Obstruction - CPB 0420
Balloon Valvuloplasty - CPB 0477
Balloon-Expandable Venous Stents - CPB 0531
Barrett’s Esophagus Surgery - CPB 0728
Bathroom and Toilet Equipment and Supplies - CPB 0429
Belimumab (Benlysta) - CPB 0818
Bell's Palsy - CPB 745
Benign Prostatic Hypertrophy (BPH) Treatments - CPB 0079
Benign Skin Lesion Removal - CPB 0633
Bevacizumab (Avastin) - CPB 0685
Biochemical Markers of Bone Remodeling - CPB 0562
Biofeedback - CPB 0132
Bio-Surgery: Medicinal Leech Therapy and Medical Maggots - CPB 0556
Biventricular Pacing (Cardiac Resynchronization Therapy)/Combination Resynchronization-Defibrillation Devices for Congestive Heart Failure - CPB 0610
Blood Product Injections for Selected Indications - CPB 0784
Body Surface Potential Mapping - CPB 0705
Bone and Tendon Graft Substitutes and Adjuncts - CPB 0411
Bone Growth Stimulators - CPB 0343
Bone Marrow or Peripheral Stem Cell Transplant for Selected Leukemias - CPB 0640
Bone Mass Measurements - CPB 0134
Bone-anchored Hearing Aid - CPB 0403
Bortezomib (Velcade) - CPB 0675
Botulinum Toxin - CPB 0113
Brachytherapy - CPB 0371
Brain Natriuretic Peptide Testing - CPB 0618
BRCA Testing, Prophylactic Mastectomy, and Prophylactic Oophorectomy - CPB 0227
Breast Biopsy Procedures - CPB 0269
BreastAlert Differential Temperature Sensor - CPB 0337
Breast Ductal Lavage and Fiberoptic Ductoscopy - CPB 0517
Breast Implant Removal - CPB 0142
Breast Pumps - CPB 0421
Breast Reconstructive Surgery - CPB 0185
Breast Reduction Surgery and Gynecomastia Surgery - CPB 0017
Breast Transillumination, Electrical Impedance Scanning (EIS), and Elastography - CPB 0386
Brentuximab (Adcetris) - CPB 0823
Bronchial Thermoplasty - CPB 744
Breath Tests of Airway Inflammation: Exhaled Nitric Oxide and Exhaled Breath Condensate pH- CPB 0691
Broth Culture Testing for Interstitial Cystitis - CPB 0695
Bunionectomy - CPB 0629
Burn Garments - CPB 0062
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C
Cabazitaxel (Jevtana) - CPB 0806
Calcitonin Injection - CPB 0803
Calcitriol and Paricalcitol Injections - CPB 0022
Capsule Endoscopy - CPB 0588
Car-Ride Simulators for Infantile Colic - CPB 0523
Carbogen Inhalation Therapy - CPB 0428
Carbon Dioxide Laser for Actinic Lesions of the Skin - CPB 0427
Cardiac Catheter Ablation Procedures - CPB 0165
Cardiac CT, Coronary CT Angiography and Calcium Scoring - CPB 0228
Cardiac Devices for Occlusion of the Left Atrial Appendage - CPB 0791
Cardiac Event Monitors - CPB 0073
Cardiac Rehabilitation - CPB 0021
Cardiopulmonary Exercise Testing - CPB 0825
Cardiovascular Disease Risk Tests - CPB 0381
Cardiovascular Monitoring Equipment for Home Use: Pulse, Blood Pressure, Telemonitors, and Pacemaker Monitors - CPB 0548
Cardioverter-Defibrillators - CPB 0585
Carotid Sinus Stimulation for Hypertension - CPB 0820
Cataract Removal Surgery - CPB 0508
Celiac Disease Laboratory Testing - CPB 0561
Cerebral Perfusion Studies - CPB 0663
Certolizumab Pegol (Cimzia) - CPB 0761
Cervical Cancer Screening and Diagnosis - CPB 0443
Cervical Traction Devices - CPB 0453
Cetuximab (Erbitux) - CPB 0684
Chelation Therapy - CPB 0234
Chemotherapy Inpatient - CPB 0570
Chest Physiotherapy and Airway Clearance Devices - CPB 0067
Chiropractic Services - CPB 0107
Chlamydia Trachomatis – Screening and Diagnosis - CPB 0433
Cholecystokinin Cholescintigraphy - CPB 0266
Chronic Fatigue Syndrome - CPB 0369
Chronic Pain Programs - CPB 0237
Chronic Vertigo - CPB 0238
Clinical Trials, Coverage of Routine Patient Care Costs - CPB 0466
Clotting Factors - CPB 0131
Coblation Non-thermal Volumetric Tissue Reduction - CPB 0475
Cochlear Implants and Auditory Brainstem Implants - CPB 0013
Cognitive Rehabilitation - CPB 0214
Cold Laser and High-Power Laser Therapies - CPB 0363
Color-Flow Doppler Echocardiography in Adults - CPB 0008
Colorectal Cancer Screening - CPB 0516
Comparative Genomic Hybridization (CGH) - CPB 0787
Complementary and Alternative Medicine - CPB 0388
Complex Regional Pain Syndrome (CRPS) / Reflex Sympathetic Dystrophy (RSD): Treatments - CPB 0447
Compression Garments for the Legs - CPB 0482
Computerized Corneal Topography - CPB 0130
Computerized Motion Diagnostic Imaging - CPB 0432
Computerized Wheeze Detectors - CPB 0813
Constraint-Induced Therapy - CPB 0665
Contact Dissolution for Gallstones - CPB 0509
Contact Lenses and Eyeglasses - CPB 0126
Continuous Passive Motion (CPM) Machines - CPB 0010
Convection-Enhanced Intraparenchymal Delivery of Drugs to the Brain - CPB 0731
Core Decompression for Avascular Necrosis - CPB 0753
Corneal Graft with Amniotic Membrane Transplantation - CPB 0293
Corneal Pachymetry - CPB 0681
Corneal Remodeling - CPB 0023
Coronary Artery Brachytherapy and Other Adjuncts to Coronary Interventions - CPB 0491
Cosmetic Surgery - CPB 0031
Coumadin (Warfarin) To Heparin Conversion Before And After Elective Surgery - CPB 0200
Cranial Remodeling - CPB 0379
Crit-Line In-Line Monitor - CPB 0373
Cryoablation - CPB 0100
Cryoanalgesia and Therapeutic Cold - CPB 0297
Cryopyrin-Associated Periodic Syndromes: Treatments - CPB 0770
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D
Deep Brain Stimulation - CPB 0208
Defecography - CPB 0718
Dehydration Testing for Endolymphatic Hydrops (Meniere's Disease) - CPB 0571
Dendritic Cell Immunotherapy - CPB 0377
Denosumab (Prolia and Xgeva) - CPB 0804
Dental Services and Oral and Maxillofacial Surgery: Coverage Under Medical Plans - CPB 0082
Dermabrasion, Chemical Peels, and Acne Surgery - CPB 0251
Devices for Post-Operative Use Following Endoscopic Sinus Surgery - CPB 0840
Dexamethasone Suppression Test in Psychiatry - CPB 0306
Diabetes Tests, Programs and Supplies - CPB 0070
Diabetic Neuropathy: Selected Treatments - CPB 0729
Diagnosis of Vaginitis - CPB 0643
Diphtheria, Tetanus, and Pertussis Vaccines - CPB 0653
Discography - CPB 0733
Distal Interphalangeal (DIP), Metacarpophalangeal (MCP) and Proximal Interphalangeal (PIP) Joint Implants - CPB 0798
Distraction Osteogenesis for Craniofacial Defects - CPB 0549
Distraction Osteosynthesis - CPB 0220
Donor Lymphocyte Infusion - CPB 0638
Dorsal Column Stimulation - CPB 0194
Double Balloon Enteroscopy - CPB 0737
Drug-Eluting Stents - CPB 0621
Dry Eyes - CPB 0457
Dry Hydrotherapy (Hydromassage, Aquamassage, Water Massage) - CPB 0699
Dupuytren's Contracture: Treatments - CPB 0800
Dysphagia Therapy - CPB 0625
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E
Early Intervention Programs - CPB 0444
Eating Disorders - CPB 0511
Eculizumab (Soliris) - CPB 0807
Electric Tumor Treatment Fields - CPB 0827
Electrical Stimulation for Chronic Ulcers - CPB 0680
Electrical Stimulation for Nausea, Vomiting and Motion Sickness (PrimaBella and ReliefBand) - CPB 0676
Electrical Stimulation for Pain - CPB 0011
Electrical Stimulation for Xerostomia - CPB 0302
Electrocochleogram and Perilymphatic Pressure Measurement - CPB 0564
Electroconvulsive Therapy - CPB 0445
Electroencephalographic (EEG) Video Monitoring - CPB 0322
Electromagnetic Navigation-guided Bronchoscopy - CPB 0776
Electrothermal Arthroscopy - CPB 0545
Enbrel (Etanercept) - CPB 0315
Endometrial Ablation - CPB 0091
Endometrial Cancer Screening and Diagnosis - CPB 0769
Endoscopic Ultrasonography - CPB 0446
Endothelial Cell Photography - CPB 0538
Endovascular Repair of Aortic Aneurysms - CPB 0651
Enfuvirtide (Fuzeon) - CPB 0671
Enzyme-replacement Therapy for Lysosomal Storage Disorders - CPB 0442
Epilepsy Surgery - CPB 0394
Epiretinal Radiation Therapy - CPB 0756
Erectile Dysfunction - CPB 0007
Eribulin Mesylate (Halaven) - CPB 0831
Ernest or Eagle’s Syndrome (Stylomandibular Ligament Pain): Treatment with Radiofrequency Thermoneurolysis - CPB 0400
Erythropoesis Stimulating Agents - CPB 0195
Esophageal Doppler Monitoring - CPB 0793
Esophageal pH Monitoring - CPB 0667
Ethanol Injection for Thyroid Lesions - CPB 0395
Evacuation of Meibomian Glands - CPB 0797
Evoked Potential Studies - CPB 0181
Extended Ophthalmoscopy - CPB 0767
External Breast Prosthesis - CPB 0097
External Counterpulsation (ECP) - CPB 0262
External Ocular Photography - CPB 0734
Extracorporeal Immunoadsorption (Prosorba column) - CPB 0355
Extracorporeal Membrane Oxygenation (ECMO) - CPB 0546
Extracorporeal Photochemotherapy (Photopheresis) - CPB 0241
Extracorporeal Shock-Wave Therapy for Musculoskeletal Indications - CPB 0649
Eye Movement Desensitization and Reprocessing (EMDR) Therapy - CPB 0583
Eye Prosthesis - CPB 0619
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F
Face Transplantation - CPB 0819
Facial Prostheses, External - CPB 0620
Fecal Incontinence Treatments - CPB 0611
Female Sexual Dysfunction (FSD) - CPB 0574
Femoro-Acetabular Surgery for Hip Impingement Syndrome - CPB 0736
Fetal Echocardiograms - CPB 0106
Fetal Fibronectin, Inflammatory Biomarkers, and Salivary Estriol Testing for Preterm Labor - CPB 0166
Fetal Surgery In Utero - CPB 0449
Fiberoptic Endoscopic Evaluation of Swallowing (FEES)/Fiberoptic Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST) - CPB 0248
Fibroid Treatment - CPB 0304
Flow Cytometry, DNA Ploidy, and S-phase Fraction - CPB 0351
Fluidized Therapy (Fluidotherapy) - CPB 0450
Foot Orthotics - CPB 0451
Frenectomy for Ankyloglossia - CPB 0116
Functional Electrical Stimulation and Neuromuscular Electrical Stimulation - CPB 0677
Functional Magnetic Resonance Imaging - CPB 0739
Fundus Photography - CPB 0539
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G
Gait Analysis and Electrodynogram - CPB 0263
Gastric Pacing and Gastric Electrical Stimulation - CPB 0678
Gastroesophageal Reflux Disease (GERD): Treatment Devices - CPB 0213
Gastrointestinal Function: Selected Tests - CPB 0396
Gender Reassignment Surgery - CPB 0615
General Anesthesia and IV Sedation for Oral and Maxillofacial Surgery and Dental Services - CPB 0124
Genetic Counseling - CPB 0189
Genetic Testing - CPB 0140
Glaucoma Surgery - CPB 0484
Glaucoma Testing - CPB 0622
Golimumab (Simponi) - CPB 0790
Gonadotropin-Releasing Hormone Analogs and Antagonists - CPB 0501
Gout - CPB 0810
Graves' Ophthalmopathy Treatments - CPB 0419
Grenz Ray Therapy for Skin Disorders - CPB 0231
Grid Monitoring: Presurgical Evaluation for Persons with Intractable Seizures - CPB 0289
Growth Hormone (GH) and Growth Hormone Antagonists - CPB 0170
Guillain-Barre Syndrome Treatments - CPB 0732
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H
Hair Analysis - CPB 0300
Hammer Toe Repair - CPB 0636
Hand Transplantation - CPB 0816
Headaches: Invasive Procedures - CPB 0707
Heart Transplantation - CPB 0586
Heart-Lung Transplant - CPB 0597
Heating Devices - CPB 0540
Helicobacter pylori Infection Testing - CPB 0177
Hematopoietic Colony-Stimulating Factors (CSFs) - CPB 0055
Hematopoietic Stem Cell Transplant for Solid Tumors in Adults - CPB 811
Hemodialysis for Schizophrenia - CPB 0291
Hepatitis A Vaccine - CPB 0048
Hepatitis B Vaccine - CPB 0410
Hepatitis Screening - CPB 0835
Hereditary Angioedema - CPB 0782
High Dose Chemotherapy and Bone Marrow or Peripheral Stem Cell Transplantation for Chronic Myelogenous Leukemia - CPB 0674
High Dose Chemotherapy and Bone Marrow or Peripheral Stem Cell Transplant for Selected Childhood Solid Tumors - CPB 0496
High Dose Chemotherapy Bone Marrow or Peripheral Stem Cell Transplant for Hodgkin's Disease - CPB 0495
High Dose Chemotherapy with Bone Marrow or Peripheral Stem Cell Transplant for Multiple Myeloma - CPB 0497
High Dose Chemotherapy with Bone Marrow or Peripheral Stem Cell Transplant for Non-Hodgkin's Lymphoma - CPB 0494
High Dose Chemotherapy with Bone Marrow or Peripheral Stem Cell Transplant for Ovarian Cancer - CPB 0635
High Dose Chemotherapy with Bone Marrow or Peripheral Stem Cell Transplant for Testicular Cancer - CPB 0617
High-Dose Chemotherapy with Hematopoietic Stem Cell Support for Breast Cancer - CPB 507
High-Frequency Pulsed Electromagnetic Stimulation - CPB 0175
High Intensity Focused Ultrasound - CPB 0766
High-Resolution Anoscopy - CPB 0808
Hippotherapy - CPB 0151
Hip and Shoulder Resurfacing - CPB 0661
Histamine Desensitization Therapy for Intractable Headaches - CPB 0647
HIV Drug Susceptibility and Resistance Tests - CPB 0316
HIV Testing - CPB 0542
Holter Monitors - CPB 0019
Home Behavioral Healthcare Services - CPB 0730
Home Births - CPB 0329
Home Cholesterol Monitors - CPB 0367
Home Dialysis - CPB 0541
Home Health Aides - CPB 0218
Home Hemoglobin Testing Devices - CPB 0824
Home Uterine Activity Monitoring - CPB 0127
Home/Ambulatory Spirometry - CPB 0572
Homocysteine Testing - CPB 0763
Hospital Beds and Accessories - CPB 0543
Hospitalization for the Initiation of Ketogenic Diet for the Treatment of Intractable Seizures - CPB 0226
Human Fibrinogen Concentrate (RiaSTAP) - CPB 792
Human Papillomavirus (HPV) Vaccines - CPB 0726
Huntington's Disease - CPB 0614
Hyperbaric Oxygen Therapy (HBOT) - CPB 0172
Hyperhidrosis (Hyperhydrosis) - CPB 0504
Hyperthermia in Cancer Therapy - CPB 0278
Hypertrophic Scars and Keloids - CPB 0389
Hypoxic Ischemic Encephalopathy - CPB 0812
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I
Ibandronate Sodium (Boniva) Injection - CPB 0727
Idiopathic Scoliosis - CPB 0398
Immune Globulins for Post-exposure Prophylaxis - CPB 0544
ImmuKnow (Transplantation Immune Cell Function Assay) - CPB 773
Implantable Hearing Aids -CPB-0612
Implantable Hormone Pellets - CPB 0345
Implantable Left Atrial Hemodynamic Monitor - CPB 0832
Implantable Vas Deferens Occlusion Devices - CPB 0027
Indirect Measurement of Left Ventricular Filling Pressure (LVFP): The VeriCor System - CPB 0704
Indocyanine Green Angiography - CPB 0111
Infertility - CPB 0327
Inflammatory Bowel Disease: Serologic Markers and Pharmacogenomic and Metabolic Assessment of Thiopurine Therapy - CPB 0249
Influenza Rapid Diagnostic Tests - CPB 0476
Influenza Vaccine - CPB 0035
Infrared Therapy - CPB 0604
Infusion Pumps - CPB 0161
Injectable Medications - CPB 0020
Inpatient Admission Prior to Surgery (Preop Days) - CPB 0255
Insulin-Like Growth Factor-1 (IGF-1) Analogues: Mecasermin (Increlex) and Mecasermin Rinfabate (Iplex) - CPB 0711
Intensity Modulated Radiation Therapy - CPB 0590
Interferons - CPB 0404
Interleukin-2 (Aldesleukin, Proleukin, IL-2) - CPB 0024
Intermittent Intravenous Insulin Therapy - CPB 0742
Intermittent Pneumatic Compression Devices - CPB 0500
Internal Fixation of Rib Fracture - CPB 0822
Interstitial Laser Therapy - CPB 781
Intervertebral Disc Prostheses - CPB 0591
Intestinal Rehabilitation Programs - CPB 0342
Intestinal Transplantation - CPB 0605
Intra-coronary Hyperoxemic Therapy - CPB 0801
Intra-operative Electromyographic Monitoring - CPB 0697
Intra-oral Appliances for Headaches - CPB 0688
Intra-vascular Optical Coherence Tomography - CPB 0829
Intragastric Hypothermia - CPB 0527
Intraoperative Radiation Therapy (IORT) - CPB 0721
Intravascular Ultrasound - CPB 0382
Intravenous Iron Therapy - CPB 0575
Invasive Prenatal Diagnosis of Genetic Diseases - CPB 0358
In Vivo Analysis of Colorectal Polyps and Crohn's Disease - CPB 0783
Iontophoresis - CPB 0229
Ipilimumab (Yervoy) - CPB 0815
Irreversible Electroporation (NanoKnife) - CPB 0828
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J
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K
Kidney Transplantation - CPB 0493
Kineret (Anakinra) - CPB 0595
Knee Ligament Arthrometer Testing - CPB 0397
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L
Laminoplasty - CPB 0576
Laparoscopic Uterine Nerve Ablation (LUNA) and Presacral Neurectomy (PSN) - CPB 0754
Laser Neurolysis - CPB 0552
Laser Photocoagulation of Drusen - CPB 0609
Laser Treatment for Psoriasis and Other Selected Skin Conditions - CPB 0577
Lead Testing - CPB 0553
Learning Disabilities, Dyslexia, and Vision - CPB 0078
Levator Syndrome Treatments - CPB 0679
Liver and Other Neoplasms - Treatment Approaches - CPB 0268
Liver Transplantation - CPB 0596
Low Vision Programs - CPB 0580
Low-Molecular-Weight Heparins - CPB 0346
Lower Limb Prostheses - CPB 0578
Lumbar Traction Devices - CPB 0569
Lung Cancer Screening - CPB 0380
Lung Imaging Fluorescence Endoscopy (LIFE) - CPB 0581
Lung Transplantation - CPB 0598
Lung Volume Reduction Surgery - CPB 0160
Lyme Disease and other Tick-Borne Diseases - CPB 0215
Lymphedema - CPB 0069
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M
Macular / Foveal Translocation - CPB 0409
Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MRV) - CPB 0094
Magnetic Resonance Cholangiopancreatography - CPB 0384
Magnetic Resonance Imaging (MRI) of the Breast - CPB 0105
Magnetic Resonance Imaging of the Cardiovascular System - Cardiac MRI- CPB 0520
Magnetic Resonance Neurography - CPB 0387
Magnetic Resonance Spectroscopy (MRS) - CPB 0202
Magnetic Source Imaging/Magnetoencephalography - CPB 0279
Mammography - CPB 0584
Manipulation Under Anesthesia - CPB 0204
Maze Procedure - CPB 0225
Mechanical Stretching Devices for Contracture and Joint Stiffness - CPB 0405
Melanoma Vaccine - CPB 0557
Melodic Intonation Therapy for Persistent Aphasia - CPB 0284
Menaflex - CPB 0786
Meniere's Disease Surgery - CPB 0514
Meningococcal Vaccine - CPB 0356
Metabolic and Environmental Profiling for Kidney Stone Risk - CPB 0392
Metatarsal Phalangeal Joint Replacement - CPB 0708
Microwave Thermotherapy for Breast Cancer - CPB 0682
Mifepristone (RU 486) - CPB 0465
Migraine and Cluster Headache: Nonsurgical Management - CPB 0462
Mohs Micrographic Surgery - CPB 0383
Motor Cortex Stimulation - CPB 0755
MRI and CT of the Spine - CPB 0236
MRI of the Extremities - CPB 0171
Multiple Sclerosis - CPB 0264
Multiple Sleep Latency Test (MSLT) - CPB 0330
Myoelectric Upper Limb Prostheses - CPB 0399
Myringotomy and Tympanostomy Tube - CPB 0418
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N
Natalizumab (Tysabri) - CPB 0751
Near-Infrared Spectroscopy and Thermal Perfusion Probe for Monitoring Regional Cerebral Blood Flow - CPB 0703
Near-Infrared (NIR) Spectroscopy - CPB 0796
Nebulizers - CPB 0065
Negative Pressure Wound Therapy - CPB 0334
Neonatal Hyperbilirubinemia - CPB 0332
Nerve Conduction Velocity Studies - CPB 0502
Nerve Fiber Density Measurement - CPB 0774
Nerve Grafting: Selected Indications - CPB 0416
Nesiritide (Natrecor) - CPB 0709
Neuralgia Inducing Cavitational Osteonecrosis (NICO) and Ultrasonograph Bone Densitometer to Detect NICO - CPB 0642
NeuroControl Freehand System - CPB 0378
Neuropsychological and Psychological Testing - CPB 0158
Nitric Oxide, Inhalational (INO) - CPB 0518
Nocturnal Enuresis Treatments - CPB 0431
Noncontact Normothermic/Nonthermal Wound Therapy - CPB 0372
Non-invasive Negative Pressure Ventilation: Body Ventilators and Poncho Wrap - CPB 0298
Non-myeloablative Bone Marrow/Peripheral Stem Cell Transplantation (Mini-Allograft / Reduced Intensity Conditioning Transplant) - CPB 0634
Noninvasive Down Syndrome Screening - CPB 0282
Noninvasive Positive Pressure Ventilation - CPB 0452
Noninvasive Tests for Hepatic Fibrosis - CPB 0690
Nutritional Counseling - CPB 0049
Nutritional Support - CPB 0061
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O
Obesity Surgery - CPB 0157
Obsolete and Unreliable Tests and Procedures - CPB 0438
Obstetrical Hypertension Programs - CPB 0368
Obstructive Sleep Apnea in Adults - CPB 0004
Obstructive Sleep Apnea in Children - CPB 0752
Occupational Therapy Services - CPB 0250
Ocular Photoscreening - CPB 0689
Ofatumumab (Arzerra) - CPB 0794
Open Air, Low Field Strength, and Standing MRI Units - CPB 0093
Optic Nerve and Retinal Imaging Methods - CPB 0344
Optic Nerve Decompression Surgery - CPB 0415
Oral Brush Biopsy - CPB 0686
Oral Screening and Lesion Identification Systems - CPB 0760
Ornish Cardiac Treatment Program - CPB 0267
Orthognathic Surgery - CPB 0095
Orthopedic Casts, Braces and Splints - CPB 0009
Osteoarthritis of the Knee: Selected Treatments - CPB 0673
Osteochondral Autografts (Mosaicplasty, OATS) - CPB 0637
Outpatient Medical Self-Care Programs - CPB 0169
Ovarian Vein Embolization for Pelvic Congestion Syndrome - CPB 0441
Oxaliplatin (Eloxatin) - CPB 0683
Oxygen - CPB 0002
Ozurdex (Dexamethasone Intravitreal Implant) - CPB 0795
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P
Paclitaxel, Albumin-Bound (Abraxane) - CPB 0834
Pamidronate (Aredia) - CPB 0672
Pancreas Kidney Transplantation - CPB 0587
Pancreas Transplantation Alone and Islet Cell Transplantation - CPB 0601
Pancreaticoduodenectomy (Whipple Resection) for Zollinger-Ellison Syndrome - CPB 0365
Panitumumab (Vectibix) - CPB 0748
Paralytic Lagophthalmos: Treatments - CPB 0366
Paranasal Sinus Ultrasound for the Evaluation of Sinusitis - CPB 0694
Parenteral Immunoglobulins - CPB 0206
Parkinson's Disease - CPB 0307
Peak Flow Meters - CPB 0059
Pectus Excavatum and Poland's Syndrome: Surgical Correction - CPB 0272
Pediatric Intensive Feeding Programs - CPB 0809
Pedobarography - CPB 0294
Pemetrexed (Alimta) - CPB 0687
Percutaneous Transluminal Septal Myocardial Ablation (PTSMA) - CPB 0558
Peripheral Artery Stents - CPB 785
Peripheral Atherectomy - CPB 0295
Peripheral Ultrafiltration for Acute Decompensated Heart Failure - CPB 741
Peripheral Vascular Rehabilitation Programs - CPB 0458
Pervasive Developmental Disorders - CPB 0648
Pharmacogenetic Testing - CPB 0715
Phonophoresis - CPB 0210
Photodynamic Therapy - CPB 0375
Phototherapy and Photochemotherapy (PUVA) for Skin Conditions - CPB 0205
Phototherapy for Acne - CPB 0656
Phototherapy for Psychiatric Disorders - CPB 0370
Physical Therapy Services - CPB 0325
Pillows and Cushions - CPB 0456
Plantar Fasciitis Treatments - CPB 0235
Plasmapheresis/Plasma Exchange/Therapeutic Apheresis - CPB 0285
Plerixafor Injection (Mozobil) - CPB 0779
Pneumococcal Vaccine - CPB 0037
Polio Vaccine - CPB 0402
Polymerase Chain Reaction Testing: Selected Indications - CPB 0650
Pool Therapy, Aquatic Therapy or Hydrotherapy - CPB 0174
Positron Emission Tomography (PET) - CPB 0071
Post-Herpetic Neuralgia - CPB 0725
Pralatrexate (Folotyn) - CPB 0740
Preconceptional Sex Selection Techniques - CPB 0323
Premenstrual Syndrome/Premenstrual Dysphoric Disorder - CPB 0512
Prenatal Care Provided by Primary Care Physicians - CPB 0047
Pressure Reducing Support Surfaces - CPB 0430
Procalcitonin (PCT) - CPB 771
Progestins - CPB 0510
Prolotherapy - CPB 0207
Propranolol for Infantile Hemangioma - CPB 0817
Prostate Cancer Screening - CPB 0521
Prostate Cancer Vaccine - CPB 0802
Prostate Saturation Biopsy - CPB 0698
Prothrombin Time (INR) Home Testing Devices - CPB 0173
Proton Beam and Neutron Beam Radiotherapy - CPB 0270
Psoriasis: Biological Therapies - CPB 0658
Ptosis Surgery - CPB 0084
Pudendal Nerve Decompression - CPB 0805
Pulmonary Hypertension Treatments and Selected Indications of Prostanoids - CPB 0184
Pulmonary Rehabilitation - CPB 0032
Pulse Oximeter for Home Use - CPB 0339
Pulsed Dye Laser Treatment - CPB 0559
Pulsed Irrigation Evacuation (PIE) - CPB 0522
Pulsed Radiofrequency - CPB 0735
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Q
Quantitative EEG (Brain Mapping) - CPB 0221
Quantitative Sensory Testing Methods - CPB 0357
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R
Radiation Treatment of Keloids - CPB 0551
Radiofrequency Tumor Ablation - CPB 0492
Radioimmunotherapy for Non-Hodgkin's Lymphoma: Ibritumomab Tiuxetan (Zevalin) and Tositumomab (Bexxar) - CPB 0659
Radiopharmaceuticals Metastron® (Strontium-89) and Samarium-153 (Quadramet) for Metastatic Bone Pain - CPB 0361
Re-breathing of Inert Gas for Measurement of Cardiac Output - CPB 0714
Recurrent Pregnancy Loss - CPB 0348
Reflex Sympathetic Dystrophy Diagnosis - CPB 0147
Remicade (infliximab) - CPB 0341
Remote Ischemic Conditioning - CPB 0814
RenalVysion - CPB 0775
Repository Corticotropin Injection (H.P. Acthar Gel) - CPB 0762
Respiratory Devices: Incentive Spirometers and Intermittent Positive Pressure Breathing Machines - CPB 0479
RET Proto-Oncogene Testing - CPB 0319
Retinopathy Telescreening Systems - CPB 0563
Retisert (Fluocinolone Acetonide Intra-vitreal Implant) - CPB 0719
Rhinometry and Rhinomanometry - CPB 0700
Ribavirin (Virazole) - CPB 0155
Rituximab (Rituxan) - CPB 0314
Robotic-assisted Rehabilitation of the Extremities - CPB 0778
Romiplostim (Nplate) - CPB 0768
Rosacea - CPB 0547
Rotavirus Vaccine - CPB 0723
Routine Foot Care - CPB 0046
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S
Safety Items - CPB 0623
Salivary Hormone Tests - CPB 0608
Scalp Cooling (Hypothermia) to Prevent Hair Loss During Chemotherapy - CPB 0290
Screening for Lipid Disorders - CPB 0525
Scrotal Ultrasonography - CPB 0532
Seat Lifts and Patient Lifts - CPB 0459
Selected Aortic Valve Procedures: Ross Pulmonary Autograft and Aortic Valve-Sparing Re-implantation - CPB 0407
Selective Nerve Root Blocks - CPB 0722
Selective Peripheral Denervation (Bertrand Procedure) for Spasmodic Torticollis - CPB 0401
Sensory and Auditory Integration Therapy - CPB 0256
Septoplasty and Rhinoplasty - CPB 0005
Serum Marker Screening for Down Syndrome - CPB 0464
Shoulder Arthroplasty - CPB 0837
Sialolithiasis (Salivary Stones) - CPB 0716
Signal-Averaged Electrocardiography (SAECG) - CPB 0664
Single Photon Emission Computed Tomography (SPECT) - CPB 0376
Skeletal Analysis Systems - CPB 0212
Skilled Home Health Care Nursing Services - CPB 0201
Skilled Home Private Duty Nursing Care - CPB 0136
Smallpox Vaccine - CPB 0644
Smell and Taste Disorders - Diagnosis - CPB 0390
Somatostatin Analogs - CPB 0693
Spasticity Management - CPB 0362
Speech Generating Devices - CPB 0437
Speech Therapy - CPB 0243
Spinal Surgery: Laminectomy and Fusion - CPB 0743
Spinal Ultrasound - CPB 0628
Stem Cell Transplant for Autoimmune Diseases and Miscellaneous Indications - CPB 0606
Stem Cell Transplant for Myelodysplastic Syndrome - CPB 0836
Stem Cell Transplantation for Myelofibrosis - CPB 0838
Stem Cell Transplantation for Primary Immunodeficiency Disorders - CPB 0830
Stem Cell Transplantation for Waldenstrom Macroglobulinemia - CPB 0833
Stem Cells for Bone Marrow Transplant - CPB 0190
Stereolithography - CPB 0613
Stereotactic Cingulotomy - CPB 0288
Stereotactic Radiosurgery - CPB 0083
Strabismus Repair in Adults - CPB 0566
Subtalar Implant for Foot Deformity - CPB 0669
Suction Pumps - CPB 0503
Suit Therapy - CPB 0696
Suprachoroidal Injection of Pharmacologic Agents - CPB 0777
Surface Scanning and Macro Electromyography - CPB 0112
Surgical Dressings (Wound Care Supplies) - CPB 0526
Surgical Treatments to Control Drooling (Sialorrhea) - CPB 0265
Synagis (Palivizumab) for Prevention of Respiratory Syncytial Virus (RSV) Infections - CPB 0318
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T
T-Wave Alternans - CPB 0579
Tables and Boards - CPB 0481
Temporomandibular Disorders - CPB 0028
Terbutaline Pump for Preterm Labor - CPB 0468
Teriparatide (Forteo) - CPB 0666
Thalamotomy - CPB 0153
Therabite Jaw Motion Rehabilitation System - CPB 0412
Therapeutic Chairs - CPB 0434
Therapeutic Phlebotomy - CPB 0652
Thermal Intradiscal Procedures - CPB 0602
Thermography - CPB 0029
Thoracic Electrical Bioimpedance for Cardiac Output Monitoring - CPB 0472
Thoracoscopic Sympathectomy - CPB 0310
Thyrogen (Thyrotropin Alfa) - CPB 0515
Tilt Table Testing - CPB 0299
Tinnitus Treatments - CPB 0406
Titanium Rib - CPB 0582
Total Ankle Arthroplasty - CPB 0645
Tocilizumab (Actemra) - CPB 0799
Tofacitinib (Xeljanz) - CPB 0839
Total Body Photography and Dermoscopy - CPB 0188
Total Body Plethysmography - CPB 0474
Total Hip Implants - CPB 0287
Total-Body CT Screening - CPB 0603
Tourette Syndrome - CPB 0480
Transabdominal Cerclage - CPB 0529
Transanal Endoscopic Microsurgery for Rectal Cancer - CPB 747
Transcatheter Aortic Valve Implantation - CPB 0826
Transcatheter Closure of Septal Defects - CPB 0292
Transcatheter Pulmonary Valve Implantation - CPB 0821
Transcervical Balloon Tuboplasty - CPB 0347
Transcranial Doppler Ultrasonography - CPB 0353
Transcranial Magnetic Stimulation and Cranial Electrical Stimulation - CPB 0469
Transjugular Intrahepatic Portosystemic Shunt (TIPSS) - CPB 0259
Transmyocardial and Endovascular Laser Revascularization - CPB 0163
Transpupillary Thermal Therapy - CPB 0490
Transrectal Ultrasound - CPB 0001
Transvaginal Ultrasonography for Ovarian and Endometrial Cancer Screening and Other Selected Indications - CPB 0530
Trastuzumab (Herceptin) and Pertuzumab (Perjeta) - CPB 0313
Trigeminal Neuralgia Surgery - CPB 0374
Tubal Sterilization - CPB 0657
Tuberculosis Testing - CPB 0471
Tumor Chemoresistance Assays - CPB 0245
Tumor Chemosensitivity Assays - CPB 0245
Tumor Markers - CPB 0352
Tumor Scintigraphy - CPB 0168
Turbinate Somnoplasty: Radiofrequency Ablation of Hypertrophied Nasal Turbinates - CPB 0592
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U
Ultra Rapid Detoxification (UROD) - CPB 0317
Ultrasound for Pregnancy - CPB 0199
Ultrasound Therapy for Wound Healing - CPB 746
Unicompartmental, Bicompartmental, and Bi-unicompartmental Knee Arthroplasties - CPB 0660
Upper Gastrointestinal Endoscopy - CPB 0738
Urinary Incontinence Treatments - CPB 0223
Urological Supplies - CPB 0533
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V
Vaccines for Travel - CPB 0473
Vacuum Assisted Socket System (VASS) - CPB 0630
Vagus Nerve Stimulation - CPB 0191
Varicella and Herpes Zoster Vaccines - CPB 0115
Varicocele: Selected Treatments - CPB 0413
Varicose Veins - CPB 0050
Vascular Endothelial Growth Factor Inhibitors for Ocular Neovascularization - CPB 0701
Ventricular Assist Devices - CPB 0654
Ventricular Remodeling Operation (Batista Procedure) / and Surgical Ventricular Restoration (Dor Procedure) - CPB 0182
Vertebral Axial Decompression Therapy - CPB 0180
Vesicoureteral Reflux Treatment by Endoscopic Injection of Bulking Agents - CPB 0534
Vestibular Autorotation Test (VAT) - CPB 0467
Videostroboscopy - CPB 0305
Virtual Gastrointestinal Endoscopy - CPB 0535
Viscocanalostomy and Canaloplasty - CPB 0435
Viscosupplementation - CPB 0179
Vision Therapy - CPB 0489
Visual Perceptual Training/Vision Restoration Therapy - CPB 0321
Visudyne (Verteporfin) Photodynamic Therapy - CPB 0594
Vitamin B-12 Therapy - CPB 0536
Vitiligo - CPB 0422
Vitrectomy - CPB 0393
Vocal Cord Paralysis/Insufficiency Treatments - CPB 0253
Voice Prosthesis for Voice Rehabilitation Following Total Laryngectomy - CPB 0560
Voice Therapy - CPB 0646
Vulvodynia and Vulvar Vestibulitis Treatments - CPB 0759
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W
Weight Reduction Medications and Programs - CPB 0039
Wheelchairs and Power Operated Vehicles (Scooters) - CPB 0271
Work Hardening Programs - CPB 0198
Wound Care - CPB 0244
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X
Xolair (Omalizumab) - CPB 0670
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Y
YAG Laser in Ophthalmology: Selected Indications - CPB 0354
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Z
Ziv-Aflibercept (Zaltrap) - CPB 0842
Ziconotide (Prialt) - CPB 0712
Zoledronic Acid - CPB 0524
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